Smoking Review Form If you have been advised by the surgery to submit smoking review please use this form. "*" indicates required fields YOUR DETAILSName* First Last Date of Birth*Day12345678910111213141516171819202122232425262728293031Month123456789101112Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920PhoneEmail* SMOKING REVIEWDo you currently smoke?* Yes No If 'Yes' How many cigarettes do you smoke in a day? 1 to 9 10 to 19 20 to 39 40 or more If 'No' Have you smoked in the past?* Yes No If 'No' how many cigarettes did you used to smoke in a day?* 1 to 9 10 to 19 20 to 39 40 or more Consent*This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our Privacy Policy to discover how we protect and manage your submitted data I consent to the practice collecting and storing my data from this form.CAPTCHA
